A large proportion of physicians in the U.S. still don't know how they feel about the use of pre-exposure prophylaxis (PrEP), according to a study presented at IDWeek 2014.
The study, which surveyed 105 clinicians and was developed by a team at Walter Reed National Military Medical Center, found that the physicians knew little about PrEP -- most of their answers on the survey were incorrect. Few of the physicians had actually prescribed PrEP and many did not think it was a cost-effective intervention. The team concluded that programs should be developed to train providers prior to prescribing -- and that organizations might want to restrict prescribing of PrEP to clinicians with significant experience treating HIV.
Other poster presentations addressed some of these issues, however. One found that trained staff at an urban HIV clinic in Houston, Texas, could successfully deliver PrEP to MSM and high-risk heterosexuals in context of comprehensive preventive services , though some dropped out over time. Meanwhile, a modeling study suggested that PrEP would be much more cost effective if targeted to the highest-risk individuals.
However, another poster
reported that opportunities to prescribe PrEP to just such a population receiving care at the Fenway Institute in Boston -- individuals who go on multiple courses of non-occupational post-exposure prophylaxis (NPEP) because of high-risk activity -- were being missed. It only makes sense to transition such individuals from NPEP to PrEP, but according to a survey of the patients, it wasn't happening either because clinicians were not telling their patients about PrEP, or because people were afraid to discuss their sex lives with their doctors. However, interest in PrEP was increasing in this group over time.
Each year in the U.S., there are around 50,000 new HIV infections, but in July 2012, the U.S. Food and Drug Administration (FDA) approved another tool for HIV prevention: tenofovir/emtricitabine (Truvada) as PrEP.
There has been some division within the HIV community regarding the use of PrEP, and its uptake of PrEP, at least initially, has been slow. However, the data appear clear that when PrEP is taken as recommended, Truvada has good efficacy at preventing HIV acquisition. If adherence has been an issue in clinical trials, what will happen in clinical practice -- and how might provider knowledge and views of PrEP affect this?
The Provider Survey
In order to ascertain providers' knowledge, perceptions, and attitudes on the applicability and utility of PrEP, and determine the prescribing patterns among two cohorts of primarily infectious disease doctors, the team at Walter Reed developed a 34-question survey using Survey Monkey, an online survey site which collects data anonymously. After first being piloted in five physicians to establish clarity and functionality, the survey was rolled out in 2013 to two cohorts of infectious disease staff and trainees: the Armed Forces Infectious Disease Society (AFIDS) and the Greater Washington ID Society (GWIDS). A total of 105 doctors participated, mostly working in infectious disease and as military academics.
The survey asked questions like:
- Do you feel the current literature supports the use of PrEP? (Almost 70% said no.)
- Do you feel the cost of PrEP is justifiable? (Only a quarter thought that it was.)
Providers at military treatment facilities were also asked to whom they thought PrEP should be offered.
- Patient who is sexually active with multiple partners. (Around 15% answered yes.)
- HIV-negative man trying to impregnate. (About 70% answered yes.)
- HIV-negative woman trying to conceive. (More than 80% answered yes.)
- Patient with a new sexually transmitted infection in the last 6 months. (Less than 20% said yes.)
- Monogamous heterosexual. (About 60% said yes, and roughly the same amount said the same thing for monogamous men who have sex with men.)
Results were very similar for providers at civilian hospitals. Overall, based on the 2011 U.S. Centers for Disease Control (CDC) interim guidelines, 60% of knowledge questions were incorrect. However, doctors who spent at least a quarter of their time providing HIV care had a significantly higher percentage correct.
There was limited experience using PrEP: 77% had never prescribed PrEP, and the remainder had only prescribed it to one to five patients.
The poster's authors noted that another survey's results, which were published earlier this year, found that the majority of adult infectious disease physicians across the U.S. and Canada supported PrEP, but that there were vast differences of opinion and practice.
"Success of real-world PrEP will require multidimensional programs addressing these barriers," the team from Walter Reed concluded.